2DNB (Diplomat of nationwide board), Urology, Muljibhai Patel Urological Hospital, Gujarat 387001, India.

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3Department the Urology and also Renal Transplant, Muljibhai Patel Urological Hospital, Gujarat 387001, India.


Correspondence Address: Dr. Arvind Ganpule, DNB (Diplomat of national board), Urology, Muljibhai Patel Urological Hospital, Nadiad, Gujarat 387001, India. E-mail: doctorarvind1
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Received: 10 Jul 2017 | First Decision: 1 Sep 2017 | Revised: 30 Sep 2017 | Accepted: 11 Oct 2017 | Published: 28 Dec 2017
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Abstract

Percutaneous renal access remains the cornerstone initial action in varied clinical settings. Because that obtaining the finest surgical outcome and also minimizing patient morbidity, one appropriate accessibility to the target calyx is needed. Though the website of entry depends upon anatomy that pelvicalyceal system and also indication because that access, a proper method should be offered for gaining accessibility and in ~ the same time minimizing the connected complications. This write-up describes our technique of gaining access to the pelvicalyceal system and also subsequent percutaneous nephrostomy location in a stepwise manner. Percutaneous nephrostomy, ultrasound, hydronephrosisPercutaneous nephrostomy (PCN) is a widely provided interventional procedure for top urinary diversion and decompression of the renal collecting mechanism in varied clinical settings. Regardless of it being a straightforward urological procedure, it stays technically challenging to insert that in the right method and in the right place. Many of the moment it’s since of absence of exposure that the urologist/interventional radiologist to correct method of PCN location in a stepwise manner. Goodwin et al.<1> first reported location of percutaneous trocar (needle) nephrostomy in a hydronephrotic kidney. Due to the fact that then, countless direct and also wire guided methods of PCN placement has been elucidated in literature. PCN can be done under flouroscopy, ultrasound (USG) or computed tomography guidance. In this chapter we will explain the USG guided method of PCN placement in a stepwise manner which is safe, effective and easily reproducible.


Obstructive uropathy

Benign causes: affected ureteric/pelvis calculi with secondary hydronephrosis (HN), uretericstricture disease, pelvic ureteric junction obstruction, HN associated with pregnancy, in transplant patients (e.g. HN as result of anastomotic stricture), retroperitoneal fibrosis, urosepsis, pyonephrosis. Malignant causes: HN second to tumor that urinary tract, HN secondary to carcinoma cervix/prostate<2,3>.

Urinary diversion in an attempt to heal problems such together malignant/inflammatory fistula, urinary leak or fistulas result from trauma, and hemorrhagic cystitis etc.<2,3>.


For offering route the access

Chemotherapy, antifungal/antibiotic therapy, bright stricture dilatation, antegrade ureteral stent placement, stone retrieval, endopyelotomy<2,3>.


Pre-operative preparation and also a counseling of the patient

Commonly, this procedure is done in neighborhood anesthesia (LA). Patient have to be well explained around the procedure in detail. Informed consent should be take away beforehand. Bleeding parameters must be within regular limits. Attain intravenous (IV) accessibility and antibiotics need to be given fifty percent an hour before procedure an especially particularly in patients presenting through urosepsis. For uncooperative yet willing patient, procedure should be perform under general anesthesia. Pertinent radiological pictures should be reviewed again in stimulate to decision anoptimal method for renal access.


Step 1: patience positioning

With patience in vulnerable position, a roller load is inserted underneath pelvic bone and also another under top abdomen and also chest region (as shown) so as to give enough stretching around flank region<4,5>. The side to it is in operated have to be lugged at the leaf of operating table. The area have to be cleansed through povidone iodine and draped

. In instance of loved one contraindication to prone place (compromised cardiorespiratory system etc.), this procedure can be done in supine place as well.


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Figure 1. The patient in prone position with roller load underneath upper abdomen and also chest, ab contents drops forward so as to give proper accessibility to the kidneys


Step 2: surface ar marking

If we ar PCN in quadrangle that safety developed by posterior axillary line as lateral limit, top margin the iliac comb as lower limit, lateral margin the paraspinous muscle as medial limit, the 11th and also 12th rib border as top limit, over there are much less chances of linked intrabdominal visceral injuries

<4,5>.


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Figure 2. Surface marking (concept of Quadrangle that safety): with the patience in vulnerable position, Quadrangle of security is developed by posterior axillary line together lateral limit, top margin of iliac comb as lower limit, lateral margin of paraspinous muscle as medial limit, the 11th and also 12th rib border as top limit


Step 3: USG come decide site of percutaneous puncture

USG of the diseased kidney must be done starting from medial element (Para spinal), proceeding laterally until the posterior axillary heat so regarding see posterior calyces first followed through lateral calyces thereafter and also thus to have actually an idea of level of HN, type of pathology in the renal unit

. Us in our institute usage 3.5 MHz convex transducer focused at 5-9 centimeter for adults and also 5 MHz transducer focused at 5-7 centimeter for children. Precise site of puncture depends primarily on the cause of hydronephrosis (HDN) and anatomic landmarks. For basic urinary drainage a lower pole posterior calyx is usually finest which have the right to be conveniently accessed via subcoastal approach. For accessing pelvicureteric junction (PUJ) or upper ureter, top or middle posterior calyx gives easy access and might require supracoastal puncture. Whenever possible aim need to be come puncture posterior calyces and to avoid straight pelvic puncture particularly in case of HN due to rock disease. Better visualized area of dilated renal pelvis (in mild HDN) and also both renal pelvis and also calyx (in middle to serious HDN) is chosen and also marked. The digital dotted puncture line centered over the area and directed right into selected calyx/pelvis. The shortest skin to calyceal street is chosen maintaining skin, renal parenchyma and cup that the calyx, infundibulum, and pelvis in a right line. USG guided puncture have the right to be excellent “free hand” but at our institute we always do the with aid of puncture overview as it helps in guiding the puncture needle in the right plane and depth<4,5>.


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Figure 3. (A) USG that the hurt kidney began from medial aspect and advancing laterally; (B) local anesthetic injected in ~ the website selected for percutaneous accessibility directing follow me the intended line of tract placement (puncture overview - dotted heat in incet); (C) skin scratch is made making use of No. 11 surgical scalpel; (D) a 15-cm, diamond-tipped, 18-gauge two-part trocar needle is involved in needle attachment associated with the USG probe. USG: ultrasound guidance


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Step 4: puncture technique

The 5 mL LA in type of 2% lignocaine is injected in ~ the website selected because that percutaneous accessibility and command in depths planes along the intended heat of street placement guided through puncture guide

. Little incision is made v No. 11 surgical scalpel
. A 15-cm, diamond-tipped, 18-gauge two-part trocar needle is then engaged in needle attachment connected with the USG probe
. The tip of the needle must be introduced very first through the incision website
and then progressed into deeper aircraft with needle overview (electronic dotted line on USG screen) turn on and beveled edge of the needle dealing with the probe (as beveled edge is echogenic and can it is in easily identified on USG). One need to appreciate needle advance along the dotted line into the preferred calyx
. If the needle is angled away from transducer or is turn off center, it will not be visualized top top USG. During passage, one can appreciate two tactile “pops”. The an initial one corresponds to give way of renal capsule/thoracolumbar fascia and also the second one as soon as needle enters collecting system. Needle reminder will move equivalent to renal outline throughout respiration saying entry right into renal system. As shortly as needle stellate is eliminated urine will egress (nature depends upon etiology), else gently aspirate when coming out of renal device until pee is it was observed
. At this suggest urine sample must be gathered and should be sent out for ideal tests. If pee is clear, we continue with dye research for calyceal delineation
. Target calyx will certainly be opacified first followed by pelvis and other calyces. If yet urine is turbid or pus is coming, we need to avoid dye research to avoid bacteremia.


Figure 4. (A) reminder of the needle is engaged first through the skin scratch site; (B) together the needle is progressed its tip is checked out along the dotted line; (C) egress of urine ~ removing needle stellate; (D) dye research for calyceal delineation as viewed on fluoroscopy


Step 5: guide wire insertion

Once position of needle is ensured, overview wire (0.038-inch diameter) is introduced through the needle under fluoroscopy guidance, trying come negotiate it into the ureter

or in top calyx if possible.


Figure 5. (A) overview wire is introduced and also parked right into ureter under fluoroscopy; (B) street dialatation using single step fascial dilator (14 Fr) over the overview wire using rotatory screw movements of hands; (C) dilator and guide wire should be in directly line and any overview wire kinking or buckling of kidney is avoided; (D) Malecot in ar with its opened up flower end


Step 6: tract dialatation

With assist of No. 11 operation scalpel, tract is incised by sliding scalpel end needle till dorsolumber fascia is incised. Tract then is dilated up to 14 F using solitary step fascial dilator over the overview wire utilizing rotatory screw movements of hand

. Treatment should it is in taken to stop kinking of overview wire or buckling of kidney
.


Step 7: insertion the nephrostomy over guide wire

In a comparable fashion and also direction together used during tract dilatation nephrostomy pipe is inserted with screwing movement of hand (avoid pushing) over the guide wire until it will well into the pelvis. We normally prefer to use 14 F Malecot catheter as nephrostomy tube, together it is self-retaining and also less opportunities to obtain blocked as result of its big diameter also in infective problems like pyonephrosis. When in ar Malecot catheter inner occluder is opened and also flower rotation should be evaluate under fluoroscopy accuse

. Though it’s self-retaining, we still favor to more stabilize nephrostomy v skin using non-absorbable suture material and also adhesive strapping. As soon as done occluder is taken out through the overview wire and attached come an outside drainage bag. Final position of Malecot catheter is confirmed by repeating dye study. USG need to be done at the end to view decompression that pelvic calyceal system too position that nephrostomy tube.


Post procedure care

Vitals should be tape-recorded every half hourly for first 6 h article procedure. Together the most vital indication because that nephrostomy location is obstructive uropathy, for this reason after decompression diuresis is supposed in these patients mandating close surveillance of pee output and electrolytes. Bed rest should be advised for approximately 4 h through recommencement that the preprocedural diet. If sepsis is suspected, a large spectrum injectable antibiotic is began round the clock. Nephrostomy tube must be checked for the patency periodically and also if blocked have the right to be gently washed through diluted 5 mL betadine/antibiotic solution.


Fluoroscopy guided access

A complete opacification the the device is done utilizing the chiba needle and thereafter access is obtained in the proper calyx<6>.


MDCT guided access

In cases where the collecting system is complicated with an overwhelming anatomy MDCT guided accessibility is valuable with added advantage of delineating abnormal anatomy with respect to bordering viscera and access site. Main limitations are its access and radiation exposure<7>.


Advantages of ultrasound guided technique

(1) to reduce radiation exposure both for operating staffs and also patients; (2) decreases need for contrast media; (3) decreases opportunities of major adjacent viscera body organ or significant vessel (color doppler) injury; (4) have the right to be perform in supine position; (5) have the right to be excellent safely in pregnant, pediatric patients; (6) method of choice in transplant kidney and also ectopic kidney (reduces opportunities of bowel injury); and (7) overcomes the problem of unsuccessful retrograde ureteral catheterization that is forced for comparison media injection in fluoroscopic guidance.


Disadvantages that ultrasound guided technique

Technically daunting for novice too in situation of soft or no hydronephrosis.


Tips and tricks of successful ultrasound guided puncture

(1) appropriate positioning and surface marking as described; (2) exactly identification that posterior calyx; (3) use puncture guide throughout puncture of desired calyx; (4) use diamond tipped needle instead of beveled tipped needle throughout puncture; (5) in instance of inadequate dilatation the pelvicalyceal mechanism diuretic deserve to be provided preoperatively; (6) during puncture one have to appreciate complete course of needle along the puncture guide; (7) when calyx is punctured and also dye is instilled, the target calyx must be opacified first followed through pelvis and also other calyx; (8) placement of guidewire through the target calyx into ureter or top calyx; and (9) always perform repeat ultrasound at finish of procedure to see for any residual hydronephrosis which may require another PCN placement.


Complications

(1) Hematuria: basically every patient have some amount of transient hematuria however only 1-3% of those patients need transfusion, surgery, or embolization. If provided at the time of nephrostomy itself, can be regulated by applying tamponade over the nephrostomy tract<8>; (2) pain: this is additionally one the the common complications, deserve to be controlled by oral/IV analgesics; (3) sepsis: PCN insertion in pyonephrotic kidneys can an outcome in significant bacteremia and sepsis; (4) injury to adjacent organs: pneumothorax and colonic injury are rare yet are well-known complication especially in supracoastal punctures; (5) extravasation that urine; (6) catheter dislodgement; and (7) inability to eliminate nephrostomy tube as result of crystallization.


Conclusion

USG guided technique of PCN placement is safe, effective and also easily reproducible if done through correct technique though it needs some level of discovering curve to conquer to become competent in this technique.


Declarations

Authors’ contributions

Study conception and also design, drafting that the manuscript: A. Jairath

Drafting the the manuscript, an important revision: A. Ganpule

Critical revision: M. Desai

Financial support and sponsorship

None.

Conflicts the interest

There space no conflicts of interest.

Patient consent

Not applicable.

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Ethics approval

Not applicable.


Cite This Article

JairathA, GanpuleA, DesaiM. Percutaneous nephrostomy step by step. Mini-invasive Surg2017;1:180-185. Http://dx.doi.org/10.20517/2574-1225.2017.24